Occupational Health Physical Examination Form
Employee Information
Full Name
Date of Birth
Gender
Male
Female
Other
Job Position
Department
Date of Examination
Medical History
Brief Medical History
Current Medications
Allergies
Vital Signs
Height (cm)
Weight (kg)
Blood Pressure (mmHg)
Pulse (bpm)
Physical Examination
System
Findings
General Appearance
Head & Neck
Eyes
Ears, Nose, Throat
Respiratory
Cardiovascular
Abdomen
Musculoskeletal
Neurological
Skin
Assessment / Impression
Recommendation / Work Fitness
Examiner Name
Signature
Date